DKA & Hyperosmolar State

• DKA: start 0.9% NaCl or balanced crystalloid at 500–1000 mL/h for the first 2–4 h, add insulin 0.1 U/kg/h once K⁺ ≥3.5, add dextrose when glucose hits 14 mmol/L, and treat until BOHB <0.6 with pH/HCO₃ normalized — not just the glucose.
• Insulin shifts K⁺: replace if <5.0, hold insulin if <3.5.
• HHS: glucose often >33, profound dehydration; use insulin 0.05 U/kg/h after 1 L, correcting more slowly (osmotic shifts).
• Always hunt for the trigger: infection, missed insulin, new diagnosis.
• Bicarbonate is not recommended; ~1/3 of crises are mixed DKA/HHS; watch for SGLT2 inhibitor–associated euglycemic DKA.

Managing Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

• DKA criteria: glucose ≥200 mg/dL (or any glucose if diabetes known), β-hydroxybutyrate ≥3.0 mmol/L (favored over urine ketones), pH <7.30 and/or HCO₃ <18 — anion gap is no longer diagnostic || HHS criteria: glucose >600 mg/dL, effective osmolality >300 or total >320 mOsm/kg, BOHB <3.0 mmol/L, pH ≥7.30, HCO₃ ≥15 || ≈1/3 of crises are mixed DKA/HHS · SGLT2 inhibitor–associated euglycemic DKA gets the same insulin-based treatment · bicarbonate is not routinely recommended; consider only for severe acidemia (typically pH <7.0)
• Fluids up front: 0.9% NaCl or balanced crystalloid 500–1000 mL/h initially (first 2–4 h), then reduce according to BP, HR, urine output, hydration and Na⁺; aim to replace ~50% of the deficit within 8–12 h. HF/ESKD/elderly: give smaller crystalloid boluses (e.g. 250 mL) with reassessment after each bolus
• K⁺ below 3.5 mEq/L?
• Yes
• Hold insulin; give K⁺ 10–20 mmol/h until K⁺ >3.5 mmol/L (faster K⁺ replacement will require central venous access)
• No
• Begin regular insulin: 0.1 U/kg/h IV infusion (IV bolus optional) (HHS: 0.05–0.1 U/kg/h once initial fluids given)
• When K⁺ 3.5–5.0: add 20–30 mEq KCl to each liter of fluid, targeting K⁺ 4–5 mEq/L
• Measure glucose hourly; once glucose falls <250 mg/dL (DKA) or <300 (HHS): add D5 to the fluids and cut insulin to 0.02–0.05 U/kg/h
• Treat until resolved — DKA resolution: BOHB <0.6 mmol/L and venous pH ≥7.3 or HCO₃ ≥18 (glucose and anion gap no longer used); HHS resolution: osmolality <300 mOsm/kg, glucose <250, mental status normal
• Transition: start subcutaneous basal insulin with a 1–2 h overlap before discontinuing the infusion
• Monitoring: glucose q1h · electrolytes q2–4h · stay alert for cerebral edema (esp. young patients) · hunt for the trigger (infection, missed insulin, new diabetes)